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Background: Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods: We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results: Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33-1.34). Conclusions: It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.
RESUMO
OBJECTIVES: To characterize antibiotics prescribed to older adults to guide efforts to improve antibiotic use. DESIGN: Descriptive analysis. SETTING: Ambulatory. PARTICIPANTS: Adults aged 65 and older in the United States. MEASUREMENTS: Information on outpatient antibiotic prescriptions dispensed for older adults from 2011 to 2014 was extracted from the IQVIA Xponent database. A chi-square trend analysis was conducted to assess annual changes in antibiotic prescribing rates. A descriptive analysis of prescribing rates by antibiotic, age group, sex, state, Census region, and provider specialty was conducted. RESULTS: From 2011 to 2014, outpatient antibiotic prescribing rates remained stable in older U.S. adults (P = .89). In 2014, older adults were dispensed 51.6 million prescriptions (1,115 prescriptions/1,000 persons). Persons aged 75 and older had a higher prescribing rate (1,157 prescriptions/1,000 persons) than those aged 65 to 74 (1,084 prescriptions/1,000 persons). Prescribing rates were highest in the South 1228 prescriptions/1,000 persons) and lowest in the West (854 prescriptions/1,000 persons). The most commonly prescribed class was quinolones, followed by penicillins and macrolides. Azithromycin was the most commonly prescribed drug, followed by amoxicillin and ciprofloxacin. Internists and family physicians prescribed 43% of antibiotic courses. CONCLUSION: On average, in 2014, U.S. adults aged 65 and older received enough outpatient antibiotic courses for every older adult to receive at least 1. Quinolones and azithromycin are potential targets for assessing the appropriateness of antibiotic prescribing in this population. Interventions to improve use targeting internists and family physicians in the South Census region might have the potential to have the greatest effect.